airway management in covid-19 - university of manitoba · airway management in covid-19: it’s...
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19
Airway Management in COVID-19: It’s more than just about aerosols
Hilary P. Grocott, MD, FRCPC
Professor, Departments of Anesthesia, Perioperative & Pain Medicine and Surgery University of Manitoba
Editor-in-Chief Canadian Journal of Anesthesia
@DrGrocott @CJA_Journal
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway Management in COVID-19: It’s also about hemodynamics
Hilary P. Grocott, MD, FRCPC
Professor, Departments of Anesthesia, Perioperative & Pain Medicine and Surgery University of Manitoba
Editor-in-Chief Canadian Journal of Anesthesia
@DrGrocott @CJA_Journal
COVID-19
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway Management in COVID-19: It’s also about hemodynamics
Hilary P. Grocott, MD, FRCPC
Professor, Departments of Anesthesia, Perioperative & Pain Medicine and Surgery University of Manitoba
Editor-in-Chief Canadian Journal of Anesthesia
@DrGrocott @CJA_Journal
COVID-19
TEXT QUESTIONS: 204-291-8377
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
• Stipend from the Canadian Anesthesiologists’ Society
Disclosures
TEXT QUESTIONS: 204-291-8377
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
• Not prescriptive • Information evolving • Be comfortable with uncertainty • Be adaptable with change
Disclosures
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
• Not prescriptive • Information evolving • Be comfortable with uncertainty • Be adaptable with change
Disclosures
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
• Not prescriptive • Information evolving • Be comfortable with uncertainty • Be adaptable with change
Disclosures
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
• Not prescriptive • Information evolving • Be comfortable with uncertainty • Be adaptable to change
Disclosures
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
April 7, 2020
December 1, 2019
Weekly Publications: “COVID-19” or “coronavirus” or “SARS-CoV-2”
February 12, 2020
Publ
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
April 7, 2020
December 1, 2019
Weekly Publications: “COVID-19” or “coronavirus” or “SARS-CoV-2”
February 12, 2020
Publ
icat
ions
0
100
200
300
400
500
600
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
April 7, 2020
December 1, 2019
Weekly Publications: “COVID-19” or “coronavirus” or “SARS-CoV-2”
February 12, 2020
Publ
icat
ions
0
100
200
300
400
500
600
Flattening of the curve
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
April 7, 2020
December 1, 2019
Weekly Publications: “COVID-19” or “coronavirus” or “SARS-CoV-2”
February 12, 2020
Publ
icat
ions
0
100
200
300
400
500
600
First anesthesia or critical care publication
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Can J Anesth doi: 10.1007/s12630-020-01591-x
77K downloads 43 citations
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Wax RS, Christian MD. Can J Anesth doi: 10.1007/s12630-020-01591-x
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
The COVID-19 Infodemic
Total annual downloads: 1.3M
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
The COVID-19 Infodemic
Total annual downloads: 1.3M 17 COVID-related articles
Downloads past 7 weeks: 290K
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Cook TM et al. Anaesthesia 2020 doi:10.111/anae.15054
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway Management Algorithm
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway PoCUS
Kong E Y-T et al. Can J Anesth 2018;65:473-484
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway PoCUS: cricothyroid membrane
Kong E Y-T et al. Can J Anesth 2018;65:473-484
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway PoCUS: cricothyroid membrane
thyroid cartilage
Kong E Y-T et al. Can J Anesth 2018;65:473-484
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway PoCUS: cricothyroid membrane
thyroid cartilage cricoid cartilage
Kong E Y-T et al. Can J Anesth 2018;65:473-484
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway PoCUS: cricothyroid membrane
thyroid cartilage cricoid cartilage
CTM
Kong E Y-T et al. Can J Anesth 2018;65:473-484
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Airway PoCUS: cricothyroid membrane
Kong E Y-T et al. Can J Anesth 2018;65:473-484
thyroid cartilage cricoid cartilage
CTM
Mark it prior to anesthesia induction in the “uncertain airway”
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Front Of Neck Access
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
Induce Anesthesia
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
Induce Anesthesia “Rapid Sequence Induction”
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
Induce Anesthesia
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
Optimize the cardiovascular system
Induce Anesthesia
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial effects
N = 416 hospitalized COVID-19 patients
Shi S et al. JAMA Cardiol doi: 10.1001/jamacardio.2020.0950
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial effects
N = 416 hospitalized COVID-19 patients N = 82 (19.7%) with cardiac injury
hs-Troponin-I > 99ile
Shi S et al. JAMA Cardiol doi: 10.1001/jamacardio.2020.0950
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
N = 82 (19.7%)
N = 332 (80.2%)
COVID-19: myocardial effects
Shi S et al. JAMA Cardiol doi: 10.1001/jamacardio.2020.0950
Surv
ival
(%)
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial injury pathophysiology
Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001
Increased Oxygen Demand Decreased Oxygen Supply
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial injury pathophysiology
Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001
Decreased Oxygen Supply Increased Oxygen Demand
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial injury pathophysiology
Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial injury pathophysiology
Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial injury pathophysiology
Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: myocardial injury pathophysiology
Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001
COVID-19: myocardial injury pathophysiology
Direct Myocardial Infection
Secondary Myocardial Involvement
Type-2 myocardial infarction
Most cases mixed?
Fulminant viral myocarditis
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Hemodynamic Considerations of Intubation
• “Acutely-ill” COVID-19 patient • Myocardial dysfunction
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Hemodynamic Considerations of Intubation
• “Acutely-ill” COVID-19 patient • Myocardial dysfunction • ARDS (acute respiratory distress syndrome)
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Gattinoni L et al. Intensive Care Med doi: 10.1007/s00134-020-06033-2
COVID-19: “new” concepts in ARDS
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
COVID-19: new concepts in ARDS
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
L-phenotype
• Low elastance • Low lung weight and recruitability • V/Q mismatch • Loss of hypoxic vasoconstriction • Hypoxemia-hypocapnia • “Absence” of dyspnea • Pulmonary artery pressures normal
COVID-19: new concepts in ARDS
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
L-phenotype
H-phenotype
• Low elastance • Low lung weight and recruitability • V/Q mismatch • Loss of hypoxic vasoconstriction • Hypoxemia-hypocapnia • “Absence” of dyspnea • Pulmonary artery pressures normal
COVID-19: new concepts in ARDS
• High elastance • High lung weight and recruitability • Shunt • Hypoxemia-hypercapnia • Pulmonary hypertension
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Progression of infection Patient self-inflicted lung injury (P-SILI)
L-phenotype
H-phenotype
• Low elastance • Low lung weight and recruitability • V/Q mismatch • Loss of hypoxic vasoconstriction • Hypoxemia-hypocapnia • “Absence” of dyspnea • Pulmonary artery pressures normal
COVID-19: new concepts in ARDS
• High elastance • High lung weight and recruitability • Shunt • Hypoxemia-hypercapnia • Pulmonary hypertension
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Hemodynamic Considerations of Intubation
• “Acutely-ill” COVID-19 patient • Myocardial dysfunction • ARDS • Pulmonary hypertension • RV dysfunction
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Right Ventricular Dysfunction
LV RV
Normal RV
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Right Ventricular Dysfunction
LV RV LV RV
Normal RV RV Dysfunction
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing RV failure and Pulmonary Hypertension
Hrymak C et al. Can J Cardiology 2017;33:61-71
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Transeptal gradient (TSG) & Ventricular interdependence
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
Normal: TSG = 100 mmHg Elevated PA pressures: TSG = 20 mmHg
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Transeptal gradient (TSG) & Ventricular interdependence
• TSG maintains normal RV architecture/scaffold • 20-40% of RV function depends on normal LV function • Hypotension decreases TSG • Optimize PVR
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
Normal: TSG = 100 mmHg Elevated PA pressures: TSG = 20 mmHg
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Transeptal gradient (TSG) & Ventricular interdependence
• TSG maintains normal RV architecture/scaffold • 20-40% of RV function depends on normal LV function • Hypotension decreases TSG • Optimize PVR
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
Normal: TSG = 100 mmHg Elevated PA pressures: TSG = 20 mmHg
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Transeptal gradient (TSG) & Ventricular interdependence
• TSG maintains normal RV architecture/scaffold • 20-40% of RV function depends on normal LV function • Hypotension decreases TSG • Increase in PVR decreases TSG
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
Normal: TSG = 100 mmHg Elevated PA pressures: TSG = 20 mmHg
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Right Ventricular Blood Flow/Ischemia
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Right Ventricular Blood Flow/Ischemia
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Right Ventricular Blood Flow/Ischemia
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Importance of systolic & diastolic pressure (MAP)
Right Ventricular Blood Flow/Ischemia
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Right Ventricular Blood Flow/Ischemia
Hypotension RV Ischemia
Importance of systolic & diastolic pressure (MAP)
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
2 9
5
Card
iac
Out
put
Hemodynamic Goals for RV failure: fluid loading?
Failing RV
Normal RV
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71
2 9
5
Card
iac
Out
put
Hemodynamic Goals for RV failure: fluid loading?
Failing RV
Normal RV
Don’t over-fill!
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
• Optimize fluid loading (Ringer’s Lactate 250 mL) • Avoid hypotension - vasopressors • Reduce PVR
- no acute role for pulmonary vasodilators (systemic hypotension effects)
• Inotropic support
Hemodynamic Management of the Airway in Acutely-ill COVID-19 patients
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Vasopressor and Inotropic Support for RV failure
Drug Inotropy SVR PVR Phenylephrine Norepinephrine Vasopressin Dobutamine Epinephrine Milrinone
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Hemodynamic Management of the Airway in Acutely-ill COVID-19 patients
• Optimize fluid loading (Ringer’s Lactate 250 mL) • Avoid hypotension - vasopressors • Avoid increases in PVR
- no acute role for pulmonary vasodilators (systemic hypotension effects)
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
• Optimize fluid loading (Ringer’s Lactate 250 mL) • Avoid hypotension - vasopressors • Avoid increases in PVR
- no acute role for pulmonary vasodilators (systemic hypotension effects)
• Inotropic support
Hemodynamic Management of the Airway in Acutely-ill COVID-19 patients
-
Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Drug Inotropy SVR PVR Phenylephrine Norepinephrine Vasopressin Dobutamine Epinephrine Milrinone
Vasopressor and Inotropic Support for RV failure
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Managing the Airway in Acutely-ill COVID-19 patients
“Rapid Sequence Induction”
SUMMARY
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Induce Anesthesia
Managing the Airway in Acutely-ill COVID-19 patients
“Rapid Sequence Induction”
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Induce Anesthesia
Managing the Airway in Acutely-ill COVID-19 patients
“Rapid Sequence Induction”
- rocuronium 1.5 mg/kg - ketamine + midazolam/propofol/fentanyl - Phenylephrine bolus syringe - Infusions: Norepinephrine + Epinephrine or Dobutamine
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
Induce Anesthesia
Managing the Airway in Acutely-ill COVID-19 patients
“Rapid Sequence Induction”
- rocuronium 1.5 mg/kg - ketamine + midazolam/propofol/fentanyl - Phenylephrine bolus syringe - Infusions: Norepinephrine + Epinephrine (or Dobutamine)
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Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630
@CJA_Journal @DrGrocott
TEXT QUESTIONS: 204-291-8377